Basic Information
Provider Information | |||||||||
NPI: | 1144703828 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALTER | ||||||||
FirstName: | CURTIS | ||||||||
MiddleName: | FRED | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RCP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8264 PEBBLE CREEK DR | ||||||||
Address2: |   | ||||||||
City: | CORONA | ||||||||
State: | CA | ||||||||
PostalCode: | 928801063 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9513130019 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1 HOAG DR | ||||||||
Address2: |   | ||||||||
City: | NEWPORT BEACH | ||||||||
State: | CA | ||||||||
PostalCode: | 926634162 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9497644624 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/10/2018 | ||||||||
LastUpdateDate: | 09/10/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2279P3900X | 24157 | CA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered | Neonatal/Pediatrics |
ID Information
ID | Type | State | Issuer | Description | 24157 | 01 | CA | CALIFORNIA BOARD OF RESPIRATORY CARE | OTHER | 98099 | 01 | CA | NATIONAL BOARD OF RESPIRATORY CARE | OTHER |